Workers Compensation Claim Kit - Michigan

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

BHHC MI Claims Kit Introductory Letter – 07/31/2017 (page 3 of 19)

BHC Requirements for MI Posting Notices – 05/22/2018 (page 4 of 19)

MI Form WC-PUB-005 -- Employees – Know Your Rights Poster – 05/2012 (page 5 of 19)

MI Form WC-PUB-006 – Rights and Responsibilities – 05/2012 (page 6 of 19)

MI Form 100 – Employer’s Basic Report of Injury – 08/2019 (pages 7-8 of 19)

MI From 106 – Supplemental Report of Fatal Injury – 08/2019 (page 9 of 19)

BHHC Medical History Request – 02/16/2014 (page 10 of 19)

BHHC Employee’s Authorization for Release of Information (English & Spanish) – 06/10/2019

(pages 11-12 of 19)

BHHC General Employee Accident Report – 02/16/2014 (page 13 of 19)

BHHC General Supervisor Accident Report – 02/16/2014 (page 14 of 19)

BHHC General Witness Accident Report – 02/16/2014 (page 15 of 19)

BHHC Express Scripts First Fill Form (English & Spanish) – 12/2018 (pages 16-17 of 19)

BHHC Workers’ Compensation Fraud Posters (English & Spanish) – 08/10/2017 (pages 18-19 of 19)

P.O. Box 881236, San Francisco, CA 94105 | Phone: (888) 495-8949 | bhhc.com

Dear Policyholder:

Thank you for placing your workers compensation coverage with Berkshire Hathaway Homestate Companies (BHHC). We look forward to working with you to fulfill all your workers compensation needs.

Enclosed you will find documentation necessary for the processing and administration of a claim in the event of a workplace injury, as well as important information regarding workers compensation requirements for your state (i.e. posting notices, compliance laws, etc). Please utilize the documents included to collect valid information regarding the injured employee and incident, and send the documents in when reporting the claim or upon request. Any completed document should be sent directly to BHHC using mail, e-mail, or fax. The assigned claims professional will forward necessary documentation onto the appropriate state entity.

It is critical that you promptly report all new claims using one of the following methods:

Online: 1. Go to our website: www.bhhc.com 2. Highlight “Workers Comp” in the menu 3. Highlight “Claims Center” 4. Click “Report a Claim”

Phone: (800) 661-6029 Fax: (800) 661-6984 E-mail: newclaim@bhhc.com

Michigan state law requires employers to report every industrial injury or occupational disease claim to their workers compensation carrier immediately. State law also requires that employers authorize initial medical treatment within 24 hours of knowledge that an occupational injury of illness has been sustained or reported, regardless of the legitimacy of the claim. Failure to comply may result in the loss of “medical control” and a significant increase in the potential claim cost.

We will attempt to contact you and the injured worker within 24 hours of receiving the First Report of Injury. Your cooperation in allowing the injured employee to speak with one of our Claims Professionals is appreciated.

Should you have any questions regarding the contents of this kit, a claim, or claim reporting, please contact our Customer Care Center at (888) 495-8949. Questions regarding your insurance policy or coverage should be directed to your broker or agent. We thank you for choosing BHHC as your workers compensation carrier and look forward to providing you superior customer service and compassionate care for your injured workers.

BERKSHIRE HATHAWAY HOMESTATE COMPANIES

BERKSHIRE HATHAWAY HOMESTATE INSURANCE COMPANY BROOKWOOD INSURANCE COMPANY CONTINENTAL DIVIDE INSURANCE COMPANY CYPRESS INSURANCE COMPANY OAK RIVER INSURANCE COMPANY REDWOOD FIRE AND CASUALTY INSURANCE COMPANY

BHHC Workers Compensation | Representing Financial Strength & Integrity | bhhc.com

WORKERS’ COMPENSATION POSTING REQUIREMENTS

Form WC-PUB-005 – Employees -- Know Your Rights Poster

• Post in one or more conspicuous places at all business locations

To complete the form, please enter the following information in the spaces provided: • Your company name • The name of a company representative and their phone number • Name of your designated insurance carrier

Form WC-PUB-006 – Rights and Responsibilities Poster

• Post near Form WC-PUB-005 – Employees -- Know Your Rights Poster

State of Michigan Workers' Compensation Agency

Employees -- Know Your Rights!

Remember - It is important to report your injury to your employer.

Medical Care You are entitled to reasonable and necessary medical care for work-related injuries or diseases. Employers or their insurance carriers are required by law to provide these services. During the first 28 days of treatment, your employer has the right to choose the physician. After 28 days you are free to change physicians, but you must notify your employer of the change. If you receive treatment from a physician of your choice, you shall obtain and promptly furnish a report to your employer.

If your employer refuses to provide medical care, you should contact Michigan’s Workers’ Compensation Agency at its toll-free telephone number: 1-888-396-5041.

You should not receive a bill from a health care provider for treatment of a covered work-related injury or illness. If you do receive such a bill, you should contact your employer or the employer’s insurance carrier.

Wage Loss Benefits You are entitled to weekly workers’ compensation benefits if you suffer a wage loss for more than seven consecutive days. These benefits may be claimed as long as a disability and wage loss continue. Generally, the benefit rate is 80% of your after-tax average weekly wage, subject to a maximum rate.

Vocational Rehabilitation If you are unable to perform the work that you have done previously, you are entitled to vocational rehabilitation. The number one goal is your return to work with your employer. If you cannot do this or require assistance in finding a new job, vocational rehabilitation services can help.

To be completed by the employer

Employer Name

Employer Contact Person and Telephone Number

Workers’ Compensation Insurance Carrier Name

If you have questions, please call the State of Michigan Workers’ Compensation Agency

Toll-free 1-888-396-5041

Additional information is on the agency’s website at www.michigan.gov/wca.

EMPLOYER: PLEASE POST THIS NOTICE FOR YOUR EMPLOYEES TO SEE! WC-PUB-005 (5/12)

EMPLOYEES Most workers are covered under workers’ compensation from

the date of employment. Report all injuries to your supervisor immediately. When injured, you can receive wage loss benefits, medical care,

and rehabilitation services. A compensable injury is one that has arisen “out of and in the

course of employment.” The work must cause the disability. Workers’ compensation is the “exclusive remedy” for work

injuries, meaning that in most cases you cannot sue for other damages.

There is a 7-day waiting period for benefit payments. You will not receive a workers’ compensation check for disability lasting less than 7 days. However, medical benefits should be provided from the day of injury. If your wage loss lasts longer than 7 consecutive days, you are entitled to benefits as of the 8th day. If your wage loss continues for 14 days or longer, you are entitled to receive payment for that first week of disability.

In most cases, wage loss benefits are calculated by taking the average of the highest 39 weeks of the last 52 weeks of gross wages prior to injury. This is your Average Weekly Wage (AWW). Generally you should receive 80% of the after-tax value of your AWW.

In certain circumstances, the value of discontinued “fringe benefits” such as the cost of health insurance, employer contributions to a pension plan, and vacation and holiday pay may be included in determining the AWW.

You should be paid your benefit on a weekly basis, and payments should continue as long as you are disabled and are suffering a wage loss.

Your first check is due and payable on the 14th day of disability. However, a benefit check is not considered “late” until 30 days after the due date.

If you have more than one job covered under the Act, the

earnings from Michigan employers are added together to calculate the AWW.

You may also be eligible for Family Medical Leave Act (FMLA) benefits. If you have questions, you should contact the U.S. Department of Labor.

Medical Benefits: You are entitled to all reasonable and necessary medical care including surgical, hospital, and dental services, as well as crutches, hearing apparatus, chiropractic treatment, and nursing care. These services are provided indefinitely as long as there is a need.

Choosing A Doctor: During the first 28 days of treatment, the employer has the right to choose the doctor. After that, you are free to change doctors providing that you notify the employer and insurance company, preferably in writing. You do not need authorization from the insurance company or the employer to be medically treated, as long as the treatment is reasonable and necessary, and your claim is not in dispute.

Maintaining Contact: It is extremely important that you maintain regular contact with your employer throughout the treatment and recovery period so that they are aware of your progress. Provide your employer with updated work status reports and discuss early return to work options.

Vocational Rehabilitation: If you have a work-related injury or illness which prevents you from returning to your job and you are currently receiving workers' compensation benefits, you are entitled to a maximum of 104 weeks of vocational assistance in returning to work. Vocational rehabilitation can help you return to your current job or a new one by identifying interests, skills and abilities, evaluating accommodations, providing job readiness assistance, outlining career objectives, and arranging retraining opportunities. Vocational rehabilitation services create a “win-win” scenario for employers, carriers, and injured employees, especially when utilized as an early intervention tool.

EMPLOYERS All public and most private employers in Michigan are covered

by workers’ compensation. Every employer subject to the Act must provide proof of insurance or be approved for self-insurance to ensure benefits can be paid to its workers should they become injured.

Eligible employees are covered under workers’ compensation from the date of employment.

There are severe penalties if an employer fails to provide workers’ compensation coverage.

Minors: The Act provides that an illegally employed minor is entitled to double compensation if injured.

Reporting: All claims must be reported to your insurance carrier. Form WC-100: must be filed with the Workers’ Compensation

Agency and your insurance carrier immediately upon the disability exceeding 7 consecutive days, death or specific loss. A copy of this form must also be given to the employee.

You must ensure that reasonable and necessary medical treatment is provided promptly.

You will need to provide a wage history report to the insurance carrier in order to calculate the correct benefit amount.

You are encouraged to maintain contact with your employees while they are off work, and provide appropriate light-duty work options and accommodations when possible.

INSURANCE COMPANIES Prompt and regular payment of benefits is required by law. Form WC-701: must be filed with the Workers’ Compensation

Agency (WCA) when wage loss benefits begin, change or stop.

Form WC-110: must be filed with the WCA 3 months post-injury, and every 4 months after, to report on vocational rehabilitation activity.

Form WC-107: must be filed with the WCA if a claim is disputed.

Medical services rendered are subject to the State of Michigan Health Care Rules and Fee Schedules. Injured employees are not to be “balance billed” for charges over and above the fee schedule.

Benefits are not to be stopped for non-cooperation with vocational rehabilitation, but a hearing can be requested.

WC-PUB-006 (5/12)

Workers’ Compensation Agency

Michigan’s workers’ compensation system provides wage replacement, medical treatment, and vocational rehabilitation benefits to individuals who are injured while at work. Each party in this system has rights and responsibilities that ensure the successful operation of the process.

For more information contact: State of Michigan - Workers’ Compensation Agency Toll free: 1-888-396-5041 www.michigan.gov/wca

1. Social Security Number 2. Date of injury 3. Employee name (Last, First, MI)

EMPLOYER'S BASIC REPORT OF INJURY Michigan Department of Labor and Economic Opportunity

Workers’ Disability Compensation Agency PO Box 30016, Lansing, MI 48909

An employer shall report immediately to the agency on Form WC-100 all injuries, including diseases, which arise out of and in the course of the employment, or on which a claim is made employer shall also immediately file an additional report on WC-106. See instructions on reverse side for filing/mailing procedures.

and result in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific losses. In case of death, an

I. EMPLOYEE DATA

4. Address (Number & Street) 5. City 6. State 7. ZIP Code

8. Date of birth (MM/DD/YYYY) 9. Sex 10. Number of dependents 11. Telephone number

Male Female

12. Tax filing status: A. Single B. Single, Head of Household C. Married, Filing Joint D. Married, Filing Separate

II. EMPLOYER/CARRIER DATA 13. Employer name 14. Federal ID Number

15. Injury location code 16. Mailing location code 17. UI number 18. Type of business (SIC/NAICS)

19. Employer street address 20. City 21. State 22. ZIP code

23. Insurance company name (if employer not self-insured) 24. Insurance company telephone number (if known)

III. INJURY/MEDICAL DATA 25. Last day worked 26. Date employee returned to work (if applicable) 27. Did employee die? 28. If yes, date of death

Yes No

29. Injury city 30. Injury state 31. Injury county 32. Did injury occur on employer's premises?

Yes No (If no, see item 53)

33. Case number from OSHA/MIOSHA log 34. Time employee began work 35. Time of event a.m. p.m. a.m. p.m.

If time cannot be determined, check here

36. What was the employee doing just before the incident occurred? Describe the activity, as well as the tools, equipment, or material the employee was using. Be specific.

37. How did the injury occur? Examples: “When ladder slipped on wet floor, worker fell 20 feet;” “Worker was sprayed with chlorine when gasket broke during replacement”

38. Describe the nature of injury or illness 39. Part of body directly affected by the injury or illness

40. What object or substance directly harmed the employee? Examples: concrete floor, chlorine, radial arm saw. If this question does not apply to the incident, leave it blank.

41. Name of physician or other health care professional 42. Was employee treated in an emergency room? 43. Was employee hospitalized overnight as an in-patient? Yes No Yes No

44. If treatment was given away from the worksite, where was it given? (Include name, address, city, state and ZIP code of facility)

IV. OCCUPATION AND WAGE DATA 45. Date hired 46. Total gross weekly wage (highest 39 of 52) 47. Number of weeks used 48. Value of discontinued fringes

49. Occupation (Be specific) 50. Was employee a volunteer worker? 51. Was employee certified as vocationally handicapped?

Yes No Yes No

52. Date employer notified by employee 53. If temporary service agency, provide name/address of employer where injury occurred.

V. PREPARER DATA I CERTIFY THAT A COPY OF THIS REPORT HAS BEEN GIVEN TO THE EMPLOYEE

Making a false or fraudulent statement for the purpose of obtaining or denying benefits can result in criminal or civil prosecution, or both, and denial of benefits. 54. Preparer's name (Please print or type) 55. Preparer's signature 56. Telephone number 57. Date prepared

Notice to employee: Questions or errors should be reported immediately to the individual listed above in space 54 WC-100 (Rev. 8/19) Front

If you are using this form as a replacement for the Form 301 to document the specifics of an injury or ill ness for purposes of compliance with the work-related injury and illness logging requirements, follow the instruct ions in Section A only. If you are using this form to report a workers’ compensation injury, follow the instructions in Section A and B.

Section A

This form can be used in lieu of the MIOSHA Form 301, Injury and Illness Incident Report. It is one of the first forms you must fill out when a recordable work-related injury or illness has occurred. Together with the Log of Work-Related Injuries and Illnesses (Form 300) and the accompanying Summary (Form 300A), these forms help the employer and MIOSHA develop a picture of the extent and severity of work-related incidents. Within 7 calendar days after you receive information that a recordable work-related injury or illness has occurred, you must fill out questions 1-9, 27-28, 33-45 and 54-57. According to Public Law of 1970 (P.L. 91-596) and Michigan Occupational Safety and Health Act 154, P.A. 1974, Part 11, Michigan Administrative Rule for Recording and Reporting of Injuries and Illnesses, you must keep this form on file for 5 years following the year to which it pertains. DO NOT mail this form to the Workers’ Disability Compensation Agency unless it meets the conditions listed below in Section B.

Section B

Authority: Workers' Disability Compensation Act, 408.31(1)(3) Completion: Mandatory Penalty: Workers' Disability Compensation Act, 418.631

You must complete all questions on this form if the injury or disease results in any of the following: (a) Disability extending beyond seven (7) consecutive days, not including the date of injury; (b) Death; (c) Specific loss. The original form must be mailed to the Workers’ Disability Compensation Agency, P.O. Box 30016, Lansing, MI 48909.

LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals with disabilities.

WC-100 (Rev. 8/19) Back

SUPPLEMENTAL REPORT OF FATAL INJURYMichigan Department of Labor and Economic Opportunity

Workers' Disability Compensation Agency PO Box 30016, Lansing, MI 48909

THIS REPORT IS TO BE FILED BY THE EMPLOYER IMMEDIATELY AFTER THE DEATH OF AN INJURED EMPLOYEE.

I. DECEASED EMPLOYEE 1. Social Security Number 2. Date of Injury 3. Date of Death

4. Name (Last, First, Middle Initial)

5. Street Address 6. City 7. State 8. ZIP Code

II. EMPLOYER DATA 9. Employer Name 10. Federal I.D. Number

11. Street Address 12. City 13. State 14. ZIP Code

15. Amount of Burial Expenses Paid (If Not Previously Reported) $

III. DEPENDENTS OF EMPLOYEE 16.

Name 17.

Date of Birth

18. Relationship to Deceased

(Spouse, Child, or Other - Please Specify Other)

19. Extent of Dependency

(Total/Partial)

20. Employer’s Signature 21. Title 22. Date

Authority: Completion: Penalty:

Workers’ Disability Compensation Act, R408.31(3) Mandatory Workers’ Disability Compensation Act 418.631

LEO is an equal opportunity employer/program. Auxiliary aids, services and other reasonable accommodations are available upon request to individuals

with disabilities. WC-106 (08/19)

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

MEDICAL HISTORY REQUEST

Employee Name: Date of Injury: Employer Name: Completion Date:

Please complete this form by providing your medical history for the past 5 years. This will help ensure that we are able to provide all of your medical records to your current treating physician for you to receive the proper care for your work injury.

Thank you for your cooperation.

Past Injuries, Disabilities, or Other Medical Conditions

Hospitalizations HOSPITAL NAME, ADDRESS AND PHONE DATES ADMITTED

Treating Physicians or Groups DOCTOR OR GROUP NAME, ADDRESS AND PHONE DATES OF TREATMENT

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

$UserLastFirstName$ www.bhhc.com $ClaimNumber$

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

AUTHORIZATION FOR THE RELEASE OF INFORMATION

AUTORIZACIÓN PARA LA LIBERACIÓN DE INFORMACIÓN

Claim Number / Número de Reclamo Date of Injury / Fecha de la Lesión

Employee / Empleado Date of Birth / Fecha de Nacimiento

I hereby authorize the divisions of Berkshire Hathaway Homestate Companies, their representative or bearer, to review, inspect, copy, and/or photograph any and all of the following documents: Por este medio autorizo las divisiónes de Berkshire Hathaway Homestate Companies, su representante o portador, a revisar, inspeccionar, copiar, y/o fotografiar cualquier y todo de los siguientes documentos: 1. Any and all medical records, including but not limited to office and hospital records, laboratory results, diagnostic reports and films,

psychiatric records, medical correspondences, doctor’s and nurse’s notes, and medical histories relevant to my workers’ compensation claim. I also hereby give permission to Berkshire Hathaway Homestate Company representatives to contact the attending physicians involved in the treatment of all related conditions. Cualquier y todo expediente médico, incluyendo pero no limitado, a los expedientes de la oficina y hospitales, resultados de laboratorios y filminas, expedientes psiquiátricos, correspondencia médica, notas de los doctores y enfermeros(as), e historiales médicos relevantes a mi reclamo de compensación de trabajadores. También, por este medio le doy permiso a los representantes de Berkshire Hathaway Homestate Company para comunicarse con el médico tratante envuelto en el tratamiento de todas las condiciones relacionadas.

2. All employment and human resource information including but not limited to: hiring and employment records, payroll and income statements, documentation related to this or any other relevant injury and any other information pertinent to providing benefits and services necessary for the completion of this claim. Toda información del empleo y de recursos humanos, incluyendo pero no limitado a: expedientes de contratación y empleo, declaraciones de nómina e ingresos, documentación relacionada a esta o cualquier otra lesión relevante, y cualquier otra información pertinente que provea los beneficios y servicios necesarios para completar este reclamo.

The released information is required for the following reasons: La información liberada es requerida por las siguientes razones: 1. To provide for adequate preparation, investigation, evaluation, review, and discovery of a claim for workers’

compensation benefits. Specifically, to determine the causation and the nature and extent of any possible pre-existing, concurrent or aggravating medical conditions with potential medical, legal, or factual implications in the this work-related injury or injuries.

Para proporcionar una preparación, investigación, evaluación, revisión, y descubrimiento adecuado del reclamo de beneficios de compensación de trabajadores. Específicamente, para determinar la causa y la naturaleza y extensión de cualquier posible condición médica pre-existente, concurrente o agravante con potencial médico, legal, o implicaciones fácticas en esta lesión o lesiones relacionadas al trabajo.

2. To provide the treating physician, consultant or evaluator with medical information necessary to provide you with the best possible medical care and medical advice.

Para proporcionar al médico tratante, consultor, o evaluador con la información médica necesaria para proporcionarle el mejor cuidado médico posible y consejería médica.

(CONTINUED ON PAGE 2)

(CONTINÚA EN LA PÁGINA 2)

B E R K S H I R E H A T H A W A Y H O M E S T A T E I N S U R A N C E C O M P A N Y ● B R O O K W O O D I N S U R A N C E C O M P A N Y ● C O N T I N E N T A L D I V I D E I N S U R A N C E C O M P A N Y C Y P R E S S I N S U R A N C E C O M P A N Y ● O A K R I V E R I N S U R A N C E C O M P A N Y ● R E D W O O D F I R E A N D C A S U A L T Y I N S U R A N C E C O M P A N Y

$UserLastFirstName$ www.bhhc.com $ClaimNumber$

P.O. BOX 881716 • SAN FRANCISCO CA 94188 • TOLL FREE: (800) 661-6029 • FAX: (415) 675-5469

AUTHORIZATION FOR THE RELEASE OF INFORMATION (PAGE 2)

AUTORIZACIÓN PARA LA LIBERACIÓN DE INFORMACIÓN (PÁGINA 2)

Claim Number / Número de Reclamo Date of Injury / Fecha de la Lesión

Employee / Empleado Date of Birth / Fecha de Nacimiento

3. To facilitate recovery of all benefits paid toward your workers’ compensation claim from any third party responsible for this injury.

Para facilitar la recuperación de todos los beneficios pagados por su reclamo de compensación de trabajadores de cualquier tercer parte responsable de esta lesión.

4. To ensure that you are accurately compensated for any amount of lost wages, time or resources while undergoing

evaluation, treatment and recovery for this injury.

Para asegurar que usted se encuentra compensado correctamente por cualquier cantidad de salarios, tiempo, o recursos perdidos mientras se somete a la evaluación, tratamiento, y recuperación de esta lesión.

5. To obtain any information necessary to appropriately determine further actions as a result of the injury or condition and

to prevent further issues for you and other employees. Para obtener cualquier información necesaria para determinar apropiadamente acciones adicionales como resultado de la lesión o condición, y para prevenir problemas adicionales para usted y otros empleados.

This consent and authorization is effective immediately, and is subject to revocation by the undersigned at any time except to the extent that action has been taken in reliance hereon, and if not earlier revoked, it shall terminate on conclusion of the claim without express revocation.

Este consentimiento y autorización es efectivo inmediatamente, y está sujeto a la revocación del abajo firmante en cualquier momento excepto a la extensión en que se hayan tomado acciones en dependencia con esto de aquí en adelante, y si no es revocado anteriormente, terminará con la conclusión del reclamo si no se presenta una revocación expresa.

A copy or fax is as valid as the original. Una copia o fax es tan válida como el original. -

(Names, addresses, and phone numbers of providers) (Nombres, direcciones, y números de teléfonos de los proveedores) I have read this authorization and fully understand its entire contents. I have asked questions about anything that was not clear to me and I am satisfied with the answers I have received. I understand that I have a right to receive a copy of this authorization upon my request. He leído esta autorización y entendido completamente su contenido en su totalidad. He hecho preguntas sobre todo lo que no estaba claro para mí y estoy satisfecho con las contestaciones que he recibido. Yo entiendo que tengo derecho a recibir una copia de esta autorización una vez lo solicite.

Signed / Firma

Date / Fecha

EMPLOYEE’S ACCIDENT REPORT To be completed by the injured worker

Employee name Employer name

Date of accident Time of accident Time you began work on day of accident Location of accident (specify if off-site address)

How did the injury occur? What job duties were you performing? Please describe in your own words.

What part(s) of your body was injured (indicating right and/or left)?

Have you sought any medical treatment for these injuries? If so, specify where and when.

Have you ever injured this part of your body before (yes or no)? If so, please describe how and when the previous injury(s) occurred.

What witnesses were present when the accident occurred? Please provide names if applicable.

Who did you report the injury to? When was the injury reported? Please provide name(s) and job title(s).

What did you do after the accident occurred?

The above report is true and correct: SIGNATURE: DATE FORM COMPLETED:

SUPERVISOR’S REPORT OF EMPLOYEE ACCIDENT

Employee name Employer name

Date of accident Time of accident Date accident reported Did the employee report the accident immediately? YES NO Location of accident (specify if off-site address)

How did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were reported as injured?

Has the employee sought any medical treatment for these injuries? If so, specify where and when.

What witnesses were present when the accident occurred (including self)?

Do you have any reason to question the legitimacy of the accident? If so, please explain:

Indicate working conditions present that led to accident (please check all that apply): Unused/unavailable lifting equipment Wet/slippery floor Unused/unavailable PPE (gloves, hardhat, goggles, etc.) Poor housekeeping Unused/unavailable sharps container Interaction with co-worker Unguarded or improperly guarded equipment Interaction with patient or resident Electrical exposure Interaction with customer Obstructed view Chemical exposure Lack of training Motor vehicle accident Defective tools or equipment Other: __________________________

What changes could be made to eliminate or reduce the hazard(s) identified above?

The above report is true and correct: Prepared by: Title: Date prepared:

WITNESS’ REPORT/STATEMENT OF EMPLOYEE ACCIDENT

Employee name Witness name & phone number Witness Address

Date of accident Time of accident Location of accident (specify if off-site address)

Did you witness the above-reported accident? If so, how did the injury occur? What job duties was the employee performing?

What part(s) of the employee’s body were injured? Describe the type of injury (strain, bruise, etc.)

What did the injured employee say at the time of injury? Did the injured employee complain of pain at the time of injury? If they complained of pain, please specify the body part(s).

What did the employee do after the accident occurred?

Were any other witnesses present at the time of the accident? If so, please list them below.

The above report is true and correct: Signature of witness: Date signed:

NOTE: Willfully making a false statement for the purpose of obtaining or denying benefits is a crime subject to penalties.

© 2018 Matrix Healthcare Services, Inc. | An Express Scripts Company. All Rights Reserved. CRP1806_0245 EME46657 OT48016O

Workers’ Compensation Temporary Prescription ID Card

To the Injured Worker:

On your first visit, please give this notice to any

pharmacy listed on the back side to speed the processing

of your approved workers’ compensation prescriptions.

Questions or need assistance locating a participating retail

network pharmacy? Call the Express Scripts Patient Care

Contact Center at 800.945.5951.

Atención Trabajador Lesionado:

En su primera visita, por favor entregue esta notificación a

cualquier farmacia enumerada al reverso para acelerar el

procesamiento de sus recetas aprobadas de compensación

para trabajadores (según las pautas establecidas por su

empleador).

Si tiene cualquier duda o necesita ayuda para localizar una

farmacia de venta al por menor participante de la red, por

favor llame al Centro de Contacto para Atención a Clientes

de Express Scripts, al 800.945.5951.

To the Pharmacist:

Express Scripts administers this workers’ compensation prescription program. Please follow the steps below to submit a claim. Standard first fill shall not exceed a 14-day supply or a cost of $150. This form is valid for up to 30 days from date of injury (DOI). Limitations may vary. For assistance, call Express Scripts at 888.786.9640.

Pharmacy Processing Steps

Step 1: Enter BIN number 003858

Step 2: Enter processor control WC

Step 3: Enter the group number as it appears above

Step 4: Enter the injured worker’s nine-digit ID number

Step 5: Enter the injured worker’s first and last name

Step 6: Enter the injured worker’s date of injury

Thank you for using a participating retail network

pharmacy. Even though there is no direct cost to you, it’s important that we all do our part to help control the rising cost of healthcare.

Please see other side for a list of participating retail network pharmacies.

To the Supervisor: Please fill in the

information requested for the injured worker.

Employee Information

________________ ______ _________________________ First M Last

_______________________________________________ Street Address or PO Box

___________________ __________________ __________ City State ZIP

Employer Name

________________________________________________

Express Scripts

ID#: _____________________________________

Your SSN is your temporary ID number; present to the pharmacy at the time

prescription is filled. You will receive a new ID number shortly.

Date of Injury: _______ / _______ / _______ MM/DD/YYYY

G3YA Group #:

Employee Date of Birth: _______ / _______ / _______

© 2018 Matrix Healthcare Services, Inc. | An Express Scripts Company. All Rights Reserved. CRP1806_0245 EME46657 OT48016O

A & P Acme Pharmacy Albertson’s Albertson’s/Acme Albertson’s/Osco Albertson’s/Sav-On Amerisource Bergen Anchor Pharmacies Arrow Aurora Bartell Drugs Bigg’s Bi-Lo Bi-Mart BJ’s Wholesale Club Brooks Brookshire Brothers Brookshire Grocery Bruno Carrs Cash Wise Coborn’s Costco Cub CVS D&W Dahl’s Dierbergs Discount Drugmart Doc’s Drugs Dominicks

Drug Emporium Drug Fair Drug Town Drug World Eckerd Econofoods EPIC Pharmacy

Network FamilyMeds Farm Fresh Farmer Jack Food City Food Lion Fred’s Gemmel Giant Giant Eagle Giant Foods Hannaford Harris Teeter H-E-B Hi-School Pharmacy Hy-Vee Jewel/Osco Kash n Karry Keltsch Kerr Kmart Knight Drugs Kroger LeaderNet (PSAO)

Longs Drug Store Major Value Marsh Drugs Medic Discount Medicap Medistat Meijer Minyard NCS HealthCare Neighborcare Network

Pharmaceuticals Northeast Pharmacy

Services Osco P & C Food Markets Pamida Park Nicollet Pathmark Pavilions Price Chopper Publix Quality Markets Raley’s Randalls Rite Aid Rosauers Rx Express RXD Safeway Sam’s Club

Sav-On Save Mart Schnucks Scolari’s Sedano Shaw’s Shop ‘N Save Shopko ShopRite Snyder Stop & Shop Sun Mart Super Fresh Super Rx Target Texas Oncology Srvs The Pharm Thrifty White Times Tom Thumb Tops Ukrop’s United Drugs United Supermarkets Vons Waldbaums Walgreens Walmart Wegmans Weis Winn Dixie

Participating Retail Network Pharmacies

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 Reward!For information leading to the arrest and conviction of

any co-worker, health care professional, or attorney representing a fraudulent workers compensation claim to

Berkshire Hathaway Homestate Companies (BHHC)*

In most states, it is a felony to make or cause to be made a knowingly false or fraudulent material statement in order to obtain workers compensation benefits. BHHC believes that

any party engaging in such fraud should be prosecuted to the fullest extent of the law, including jail sentences.

Please do your part to help! Putting criminals out of operation benefits all of us, including keeping your employer’s premium rates reasonable.

Call our toll-free fraud hotline immediately if you have information on a fraudulent claim:

1 (800) 300-JAIL

*Maximum reward of $1,000 per conviction. In the event that more than one individual submits information regarding the same fraudulent claim, BHHC will equally divide the reward among those providing information used in obtaining the conviction. BHHC reserves the right to determine what information, if any, will be provided to the appropriate law enforcement agency. Criminal prosecutions are the sole responsibility of the authorities and may or may not be pursued at their discretion. Any

issues regarding the intrepretation of this policy shall be resolved by BHHC at their sole discretion. Program subject to change or termination without prior notice.

BHHC Workers Compensation Division • Representing Financial Strength & Integrity

$1000 RECOMPENSA!INFORMACIÓN QUE LLEVA AL ARRESTO Y A LA CONDENA DE CUALQUIER COMPAÑERO DE TRABAJO, PROFESIONAL DE CUIDADO MEDICO, O ABOGADO QUE REPRESENTE UN

RECLAMO FRAUDULENTO EN CONTRA DE BERKSHIRE HATHAWAY HOMESTATE COMPANIES*

En la mayoría de los estados es un delito grave hacer que haga una declaración de material fraudulento para obtener beneficios de Compensación al Trabajador. Berkshire

Hathaway Homestate Companies cree que cualquier persona que se involucre en tal fraude debe ser procesado con todo el rigor de la ley, incluyendo

SER SENTENCIADO A LA CARCEL.

Ayúdenos de su parte. El poner a estos delincuentes fuera de operaciones nos beneficia a todos, incluso esto ayuda a mantener los réditos bajos de la aseguranza de su empleador.

Si usted tiene información sobre un reclamo fraudulento por favor llame de inmediato a nuestra LINEA GRATUITA DE FRAUDE.

(800) 300-JAIL

*La recompensa máxima es de $1,000 por convicción. En caso de que más de una persona presente informaciones sobre la misma demando fraudulenta. Berkshire Hathaway dividirá la recompensa por partes iguales entre aquellas persones que aportaron informaciones para obtener la convicción. Berkshire Hathaway se reserva el

derecho de determinar qué informacion presentará a la agencia judicial correspondiente. El proceso de crímenes es la responsibilidad exclusiva de las autoridades, que pueden decidir si el proceso debe entablarse or no. Cualquier disputa que pudiera surgir en la interpretación de esta ofreta será resuelta por la propia Compañia de

Seguros Berkshire Hathaway. Este programa está sujeto a cambios a cancelación sin aviso previo.